Inaccurate MDS Assessment for Hospice Care
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for a resident, leading to a deficiency. Resident 49, who was admitted with Alzheimer's disease and protein-calorie malnutrition, was receiving hospice services. However, the quarterly MDS assessment dated December 20, 2024, inaccurately indicated that the resident was not receiving hospice care. This discrepancy was confirmed during an interview with the Director of Nursing on April 17, 2025, who acknowledged that the resident was indeed receiving hospice care during the period in question.
Plan Of Correction
F0641 - Accuracy of Assessments A. Resident #49: MDS assessment modified and resubmitted to reflect the accurate assessment. B. Registered Nurse Assessment Coordinator will conduct an initial audit to identify other residents/MDS assessments with coding discrepancies for item 00110K1 (hospice). All findings will be addressed. C. Nursing Home Administrator or designee will re-educate the Registered Nurse Assessment Coordinator on RAI Manual guidelines related to 00110K1 coding. D. Nursing Home Administrator or designee will audit 00110K1 of completed MDS assessments, weekly x6 weeks, to ensure accuracy. Inaccurate coding will be addressed upon identification and results will be shared with QA committee for review.